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FOR OFFICE USE: ----- ----- -- Permit No. .�`�..�?�....- , ----------- -- ------------ APPLICATION FOR SANITATION PERMIT W--------- ------------- ------------- ----------- (Complete in Duplicated Date Issued _�:--��-- This Permit Ex fres 1 Year From Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Dor - Zzn--33 , This application is made in compliance with County Ordinance No. 549. r leS�Op IJ' .S�4��—'aµr' rrTa` t-00 JOB ADDRESS AND LOCATION__ ------------ ----- ---- Phone--------- ------------------------- Owner s Name------ - - Irl-kt---- ---------- --------------------- --------- -- • ----- ------------------------.......... Address-- ----- f Phone Contractor's Name--e-, ----- ---,�--- -"----••-- - - - -- -�'_---------- ---------- -- -- Installation will serve: Residence E] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths __.` Lot size ------------------------•--- t. Water Supply: Public system ❑ Community system ❑ Private ®o Depth to Water Table Loam ❑ Clay f❑ Adobe❑ Hardpan ❑ Gravel Sand ® Y Character of soil to a depth of 3 feet: Sand ❑ ❑ y Previous Application Made: (If yes,date----------- -----) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: y . 1 ailable within 204 feet.} (No septic tank or cesspool permitted if public sewer is av ./ /v !-----Materia4 _- C -� �. t Septic Tank: Distance from nearest well_____U____..__Distance from foundation____________ _ I-I p i �- --0 q P No. of compartments- -----------------------Sizes---- --- l- � �-Li uid depth ---- --- ---- ----- - i Disposal Field: Distance from nearest well.�_P_r_ --Distance from foundation_-_� �---------Distance to nearest lot line__S ---------- i Number of line ------ of each line_-_.___/_G�-------------Width of trench_-_ _�._"-.---------------•-- � Type of filter material-_ �_ �------------Depth of filter material--------/_- ----- Seepage -_____.total length__1 __`------------------------- I See a e Pit: Distance to nearest well----- ---'n'------mDis Distance e from foundationDiameter _Distance toDnearest lot line_.-__----__---- p 9 ❑ Number of pits-___. g Cesspool: Distance from nearest well-________________Distance from foundation------------------ Lining material-------------------------------------gals ------- ----Depth----------------------------------------------------Liquid Capacity-- ---------------- - ❑ Size: Diameter Privy: Distance from nearest well------------------------------------- -Distarce from nearest building_= -------------------------- ._--.____----------------------- ---- ❑ Distance to nearest lot line--------------------------- - -------------------- --- ---- --- --- - -- - -- ---- ----- -- Remodeling and/or repairing (describe):--------- -- ------- ------------ ------------------------------------ -------------------------- -------------------- ------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Owner and/or Contractor( Si ned --? } ------- 'r --------- ---------------- -------- ------------- -- 1— (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side. { � FOR DEPARTMENT USE ONLY \ DATE----`'/_-~- APPLICATION ACCEPTED BY-_."',-,-- -- - -- '--7 " --------- ---- DATE_--- ----------------------- ---------------------------- REVIEWED ----------- --REVIEWED BY----- ---------------------------- --------- --------------------------------- ------------ ---------------- --- DATE---------------------------- BUILDING PERMIT ISSUED----- ---------- ---------- ----------- ---------------------- -------- - ------- Alterations and/or recommendations:.......................--------------------------------------------------- -- ------------.---- FINAL INSPECTION BY:_. _ __... - . Date.- - ---------- ---------- SAN -------- AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracyr California F.P.co.